Provider Demographics
NPI:1750432787
Name:GLUCK-SHATS, MAYA (MD)
Entity type:Individual
Prefix:DR
First Name:MAYA
Middle Name:
Last Name:GLUCK-SHATS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:20 GRAND ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990-1035
Mailing Address - Country:US
Mailing Address - Phone:845-987-3906
Mailing Address - Fax:845-987-5979
Practice Address - Street 1:26 FIREMENS MEMORIAL DR
Practice Address - Street 2:STE 215
Practice Address - City:POMONA
Practice Address - State:NY
Practice Address - Zip Code:10970-3553
Practice Address - Country:US
Practice Address - Phone:845-354-0011
Practice Address - Fax:845-354-0147
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY118139207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01541675Medicaid
NY35L621Medicare PIN
NY01541675Medicaid